Prescription Drugs (YNHHS Plan)

What you need to know

You automatically have prescription drug coverage when you enroll in the YNHHS Medical Plan. You can fill covered prescriptions at participating CVS retail pharmacies, through mail order, or through YNHHS Outpatient Pharmacy Services.

Need to fill a prescription?

Find a participating pharmacy near you.

Filling Your Prescription

Your prescription will be covered only if it’s filled at a participating pharmacy. To fill 30-day supply prescriptions, just present your prescription and CVS Caremark prescription drug card at a pharmacy in the CVS Caremark network. To fill a maintenance medication, you must use a CVS retail pharmacy, mail order, or visit a YNHHS Outpatient Pharmacy. For specialty medications, you’ll need to use mail order or specialty pharmacy services, as described below.

In an emergency or if you’re out of state and can’t get to a participating pharmacy, you’ll pay out of pocket and then file a claim for reimbursement from CVS Caremark.

When you’re covered by the YNHHS Medical Plan, the out-of-pocket maximum is the most you’ll pay out of pocket for medical care and prescription drugs.

When a generic is available and you or your doctor chooses a brand-name drug, you’ll pay the brand-name coinsurance—plus the difference in cost between the two medications.
Pay nothing for certain preventive drugs

The Affordable Care Act (ACA) makes many prescription medications, vaccines, and supplements—including contraceptives and statins—available to you at no cost.

Save on Maintenance Drugs

For medications you take on an ongoing basis, you’ll use the CVS Caremark Maintenance Choice program to get refills at a lower copay for a larger supply. With CVS Maintenance Choice, you get up to two 30-day fills at a retail pharmacy before you’ll need to use CVS Caremark mail service or a CVS Pharmacy for 90-day fills.

What You Pay for Fills

What you’ll pay depends on the type of medication and the amount prescribed. When the cost of a drug is less than the minimum copay, you’ll pay the lower amount.

Tier 1: Generic

30-day supply: $10 copay

90-day supply through CVS Maintenance Choice: $20 copay

Tier 2: Brand name
30-day supply: 20% coinsurance ($35 minimum, $80 maximum) if the drug is on the list of preferred brand drugs (the formulary)

90-day supply through CVS Maintenance Choice: 20% coinsurance ($70 minimum, $150 maximum) if the drug is on the list of preferred brand drugs (the formulary)

Tier 3: Non-preferred brand
30-day supply: 40% coinsurance ($55 minimum, $120 maximum) if the drug isn’t on the list of preferred brand drugs (the formulary)

90-day supply through CVS Maintenance Choice: 40% coinsurance ($110 minimum, $230 maximum) if the drug isn’t on the list of preferred brand drugs (the formulary)

Tier 4: Specialty

Up to a 30-day supply only through YNHHS Outpatient Pharmacy Services Generic and brand name: $20 copay

For certain high-cost specialty drugs not available through Outpatient Pharmacy Services or the Apothecary & Wellness Center, you’ll use CVS Specialty Pharmacy. These medications are subject to 40% coinsurance (up to $150 generic, $200 brand name).

Preauthorization and Other Special Circumstances

Compounded Medications
Some prescriptions, including compounded drugs, require preauthorization from CVS Caremark before they can be filled. Your pharmacist will let you know if your doctor needs to make that call.
Breast Cancer Drugs
If you’re taking raloxifene (brand name: Evista) or tamoxifen (brand name: Noladex) for primary prevention of breast cancer, these generics may be available at no cost to you through the preventive provisions of the Affordable Care Act. To learn if you qualify, your doctor will need to complete the Preventive Services Zero Cost Sharing Form and fax it to CVS Caremark.
Step Therapy Program
The step therapy program requires you to try one or two generic equivalents before the brand-name drug will be covered.

Drug classes included in this program include medications that treat high cholesterol, high blood pressure, gastrointestinal disorders (GERD, for instance), sleep disorders, depression, and other conditions.

Drugs and Supplies not Covered

The following drugs and medical supplies are not covered by the plan:

  • Medical devices and appliances
  • Experimental drugs
  • Drugs whose sole purpose is to promote or stimulate hair growth
  • Retin A (for those over age 28)
  • Weight-loss drugs
  • Immunization agents, biological sera, blood or blood plasma
  • Infertility medications
  • Most over-the-counter drugs, vitamins, and nutritional supplements
  • Ostomy supplies

Connect with…

HRConnect
Monday–Friday,
7:30 a.m. to 5 p.m. ET
844-543-2147
203-200-3838 (fax)
Website
Choose the YNHH_PRD option

CVS Caremark
800-776-1355
800-294-5979 (Preauthorization)
800-237-2767 (Specialty Pharmacy)
Website

YNHHS Outpatient Pharmacy Services (YNHHS Medical Plan)
844-881-0043
203-230-0679 (fax)
Website

Apothecary & Wellness Center
YNHH Saint Raphael Campus
203-789-4076

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